Concussions: A football question that still doesn't have enough answers

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Utah football coach Kyle Whittingham remembers playing in a USFL game when he got hit so hard in the head he didn't know where he was. With blurry eyes and a foggy mind, Whittingham relied on his instinct, which told him to get back to the huddle as fast as possible, so he got up and jogged to the group of players he saw. That is when his teammates knew something was wrong.

"I staggered over to the offensive huddle," the former linebacker said, chuckling at the memory. "My guys had to come and get me. Back then, if you got popped and could get up and find a huddle, you were good to go."

That isn't the case today. Growing awareness and concerns about the rate of concussions in football have led to more and more actions taken in an effort to minimize head injuries.

The NFL, Pop Warner and the NCAA have instituted several rules, practice limitations and stiffer penalties aimed at lessening blows to the head. The Pac-12 is implementing a Student Athlete Health and Well-Being Initiative, which will dedicate $3.5 million in research grants, a large part of which will be used to study concussions and their effects on athletes.

"You're not going to eliminate injury from athletics and you can't eliminate the fact that by the time kids come to college there are cumulative impacts," Pac-12 commissioner Larry Scott said in announcing the initiative. "But we are facilitating and adding value and resources to educate and be as smart as possible and minimize injuries."

Despite the safeguards, the rates of concussions continue to alarm those who track such statistics.

In September 2012, the NCAA's Injury Surveillance Program announced the rate of football-related concussions has been steady over an eight-year period despite rule changes and initiatives to prevent the injuries.

During the 2011 season, 2.5 concussions were reported for every 1,000 game-related exposures. The concussion rate in other fall sports in 2011, including soccer, field hockey and volleyball, was 1.9 concussions for every 1,000 game-related exposures.

The concussion rate reported in 2011 during football practices was 0.5 per 1,000 and 0.3 per 1,000 for fall sports.

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Cumulative effects • While the numbers affected might seem small, what is disturbing and unknown is how much damage cumulative hits have on athletes. Studies are linking repeated head trauma to causing a brain disease similar to Alzheimer's, and suicides among NFL players who were affected by career-spanning head trauma, notably Junior Seau, have raised public awareness.

"It's definitely a hot topic, and with all the stuff you read, we still don't know what the long-term effects are," Whittingham said. "It's definitely something we are all concerned about. Times have changed since I was a player."

Simple logic says the easiest way to protect players is give them better-padded helmets. Unfortunately, the solution isn't so easy.

Despite all the advances in helmet technology, with polycarbon this and polycarbon that, there hasn't been much headway made in the ability to shield football players from concussions.

One study, led by Adam Bartsch at the Cleveland Clinic for Spine Health, found modern-day helmets aren't any more effective at protecting players than old-fashioned leather ones when it comes to cumulative hits.

Bartsch's study was performed by using crash test dummies in simulated collisions that mimicked the speed of most on-field hits at the collegiate and high school levels.

A more recent study by Virginia Tech produced significantly different results  showing modern helmets protect skulls from 45 to 96 percent more than the old style.

However, Bartsch believes the contrasting results point to the overall troubling issue with concussions: There simply is not enough research to understand why concussions persist and how a variety of angled hits affect the brain.

Bartsch's study tested the reactions in helmets not only with linear hits like the Virginia Tech study did, but also with rotational hits, such as ones to the side of the head. Rotational hits are the more common injury in athletic settings and are believed to do more damage because the impact comes with twisting, which causes more stress to the brain.

These are the kind of hits that might not make TV highlights for their brutal impacts, but studies show they can create the most cumulative damage.

A 2010 study published in the Journal of Athletic Training showed the teams it tracked over a full season had an average of 2,500 hits to the head that measured as significant blows, and about 300 hits that were considered in the concussion-causing range.

Each team logged about 200 practice collisions that measured above 120 g's of force, which is comparable to a car crashing into a wall at 40 miles per hour.

So add up all the hours a youngster knocks heads on the playground, then in organized ball and on up through the elementary, middle school and high school years, and by the time he makes it to college, an athlete could have brain damage even though he avoided bigger shots to the head.

"Everyone wants to talk about helmets and the technology, but what we are dealing with is still a lack of understanding," Bartsch said. "There is a lot of work in the NFL being done trying to minimize the so-called 'kill shots' you see on NFL Sundays, but unfortunately there are 7 million kids being ignored who are in Pop Warner, or junior high or high school absorbing a lot of hits. We still need to collect a lot of data from the field, which can take decades, but no one wants to think in those terms."

Bartsch is working on a new research project that will track the severity and rate of hits players sustain via a sensor in the mouth guard. In his ideal scenario, the research will include young players as well as high school and college athletes.

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A sense of urgency • Bartsch and other researchers feel a sense of urgency to find answers, particularly after the suicides of several former NFL players, including Seau, who was found to have a degenerative brain disease linked to repeated head trauma, according to the National Institutes of Health.

Researchers at Boston University who have studied the disease, called chronic traumatic encephalopathy, have found it in 33 of the 34 brains of former NFL players examined by the group.

Seau's case highlights not only the prevalence of the disease, but also the difficulty in determining the extent of the damage. According to published reports, the disease wasn't detected until the tissue was examined with microscopes and staining techniques that revealed the abnormalities.

How then, can researchers not only track hits but also determine how they affect athletes in time to prevent further damage?

Utah senior safety Quade Chappuis remembers running down the field against USC on a kickoff when he got hit in the side of the head, right behind his ear.

This was just the kind of hit Bartsch worries about and the kind Utah trainers keep a sharp eye out for when players are on the field. Chappuis doesn't remember anything after the impact, other than Utah's trainers surrounding him and taking him to the locker room.

"I remember having a headache and not being able to play," he said.

Even though the headache went away a few days later, Chappuis missed the next game because he failed to meet Utah's baseline standards for concussion recovery.

These standards are set for every athlete when he or she arrives on campus. They are put through a series of cognitive and neurological tests to create a baseline of normalcy specific to that person. In addition, they are put through a conditioning exam they must pass without any symptoms after suffering a concussion.

Chappuis passed the cognitive exams, but couldn't run without the concussion symptoms returning.

"It was frustrating," he said of the experience. "I've gotten hit a lot before, but I guess it was being in the wrong place at the wrong time."

Chappuis is just one of several Utes who have missed games or practices recently due to concussions. Teammate Reshawn Hooker missed part of August's practices with a concussion as well as part of the recent spring camp, and in 2010 local star Sausan Shakerin's career ended prematurely after too many concussions.

"Getting your bell rung," might be a light way to look at concussions, but at Utah and other schools they are taken seriously, Whittingham said.

If players are injured or suspected of having a concussion, their helmets are taken from them so they can't go back on the field and they are monitored by the training staff.

"Never in this program do we second-guess our trainers and doctors, and they call the shots in determining who has a concussion and who is ready to go," Whittingham said. "It's something we handle to the extreme. It's far beyond the realm of our scope as coaches and something that should be handled by the medical staff."

Chappuis said the experience didn't and won't make him hesitant to play as hard as he can when the season starts. He acknowledges concussions are a risk players understand. Rules put in place meant to make the sport safer help, but football is still a violent sport, he said.

"When you're going full speed, you can't always control where your body is going," he said. "Sometimes you can take a hit like that."

Those instances are why researchers such as Bartsch will continue to study the complex problem, since players obviously aren't going to opt for the simple solution.

"If football players would stop hitting each other in the head, I would have to look for a new research topic," he said. 

Football helmet development

Early 1900s • The early versions of helmets were called "head harnesses," and were made of soft leather and covered the ears.

1915-1917 • The first helmets giving full protection to the skull and featuring holes in the earflaps for better communication debut.

1920-1930 • Harder leathers and some cushioning are added to the helmets, which also begin to take a more modern look rather than the flat top of earlier designs.

1939 • The first major evolution in helmets comes when the John T. Riddell Co. introduces the first plastic helmet. Riddell debuts the first face mask in 1940.

1971 • Riddell debuts its HA-91 and HA-92 helmets, which had vinyl cushions inside the helmet that could be pumped up.

1980s • Dark visors are added to some helmets to protect players with eye injuries.

2002 • Riddell debuts its Revolution helmet designed to reduce the incidence of concussions, while the Schutt Sports Group follows with its own, called a DNA. A study financed by Riddell of high school players found the annual rate of concussion was 5.3 percent for players wearing the Revolution helmet and 7.6 for players wearing standard helmets.

Sources: www.popularmechanics.com, NFL Encyclopedia, Riddell

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